Home births: it’s time to broaden the focus of the debate

In a recent post, Dr Andrew Pesce, a Sydney obstetrician and gynaecologist and former president of the Australian Medical Association, raised concerns about the safety of current home birth practices.

In the article below, Hannah Dahlen, Associate Professor of Midwifery, University of Western Sydney, and national media spokesperson for the Australian College of Midwives, suggests the need for a more wide-ranging debate whose ultimate goal should be making all births – whether they take place at home or in hospitals – as safe as possible.

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Broadening the discussion about home births

Hannah Dahlen writes:

Once again the home birth debate rears its ugly head in public, and we spin the well-worn wheels of argument in the ever deepening intellectual (or not so intellectual) rut, hoping that somehow we will gain traction with one more scientific study or State mortality report and move the debate forwards in the direction that subscribes to our particular belief system.

After more than 20 years of reading, researching and being engaged in clinical practice I have come to the conclusion that the answer to this debate is not statistics but a shared responsibility. It is time to work together on what we agree on, whilst learning to compromise or accept that which we don’t agree on.

The principles we tend to agree on include respecting the right of women to choose where and how they give birth; making sure the best evidence is provided to women making this choice; ensuring that the practitioners attending women who choose home birth are skilled, regulated and networked into a responsive system that has women at the centre and not professional self interest.

Home birth has always been a choice women have sought in every country in the world and in every epoch in history. The numbers of women having a home birth have doubled in the USA and Australia in the past four years.

Home birth will not go away, it is here to stay, so let us all share the responsibility for making it safe and satisfying, as should be our goal with all maternity care options.

The paradigm of risk in much of the developed world is one that holds home birth as risky and hospital birth as safe.

The assumption (not entirely wrong) is when things ‘go wrong’ home is not the best place to be; however conversely we could argue when things are ‘going right’, hospital is not necessarily the best place to be and can be the cause of things going wrong as women enter what has been described as the cascade of intervention.

The reality is there are advantages and disadvantages with both places of birth, therefore we are left with a couple of options – we recognise women’s choice as valid and try to reduce the disadvantages and improve the advantages of all options of care (shared responsibility), or we obstinately put our heads in the sand and hope if we ignored it long enough home birth will go away (the current attitude to home birth in Australia).

Never in history and in no country on earth has this ever happened but in some countries concerted efforts to cater for women’s choice means hospital birth and home birth have been made safer.

The continued focus on the safety of home birth in research (primarily perinatal mortality) often leads us up a blind ally – not that perinatal outcomes are not important – but they hide agendas and underlying discourses and will not end the debate.

Handpicking research to prove your point is something we are all expert in and sadly the public who trust us to provide an ethical and objective lense remain ever more confused.

So I will begin by agreeing with Dr Pesce (I think). While home birth advocates often cite research which is supportive of the safety of home birth and home birth critics cite papers that show a lack of safety, the studies examining the safety of home birth have consistently found comparable perinatal mortality among low risk women giving birth at home with a midwife, and low risk women giving birth in hospital, but lower intervention rates and maternal morbidity.

Likewise, studies have shown that when women with high-risk pregnancies give birth at home the perinatal mortality is increased. In fact, the evidence is now substantial enough that we can identify where the greatest risk lies; for example, women giving birth to twins (especially the second twin) and breech babies.

Looking at small State reports of 160 births, where one or two deaths will alter the perinatal mortality rate dramatically, is not a sensible approach.

Any statistician will tell you when events are rare, large numbers are needed to make sure statistical errors are not made. However, we should never dismiss any evidence that may help us improve our practice and we must always be willing to learn and improve.

So, if we are agreed (mostly) that homebirth for women with risk factors in their pregnancy leads to an increase in adverse outcomes compared to hospital birth, where to next?

Well this is where we must move from the current kindergarten approach of beating one another up with handpicked statistics, to the adult approach in the debate and towards a shared responsibility.

Keeping in mind the well-founded assumption that home birth is here to stay, there are three issues we need to consider. Firstly, why do women undertake a birth at home with risk factors? Secondly, how do we define safety? Thirdly, do we really want to take away a woman’s right to self-determination.

Why do women undertake a birth at home with risk factors?

The intervention rates during childbirth have skyrocketed over the past ten years in Australia, leaving many women traumatised and fearful.

A first time mother in Australia now has a greater chance of having surgical intervention during her birth than of not having it. This is not safe, either physically or psychologically. It is expensive, has many consequences and is counterproductive to optimising normal birth and healthy mothers and babies. The ramifications of these issues are: more traumatised women due to interventions during birth; fewer options of care – especially continuity of midwifery care; fewer experienced, networked midwives available to attend women privately; and limited to no access for women to a hospital birth under a private midwife.

A woman wanting to have a vaginal breech birth in hospital will often have to fight hard and search far and wide to find a doctor to support her choice. A woman wanting to have twins in hospital without being forced into having an epidural or having the second twin virtually extracted from her body, will also have to fight hard to have her choices respected. A woman wanting to have a vaginal birth after caesarean in a birth centre may find she is ‘banned’ from this option and has limited choices available to her.

So when these women seek care outside our mainstream system, whose fault is it really?

The answer to all this is not to demonise women for their choices but to stop and consider our responsibility as a society to mothers and babies.

It is time we made our maternity care system accountable and really listened to what women are telling us and how in fact we are failing them. When a woman chooses to have a homebirth with risk factors present, the question we need to ask is not ‘what is wrong with her’ but rather ‘what is wrong with a maternity care system that provides such limited options and inspires such fear that she would take on the added risk’?

These women do not love their babies less, they fear mainstream care more and this is a terrible indictment of our care.

How do we define safety?

When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

With suicide during pregnancy and the postnatal period now one of the leading causes of maternal death in Australia, the UK and USA, we are very remiss to not consider safety in a much broader context.

Cultural, emotional, social, psychological and spiritual safety rarely appear in the mainstream debates about the safety of homebirth, yet qualitative research would indicate this dominates in women’s decision making regarding choice of place of birth. Not only does it dominate women’s thinking, research indicates ignoring its importance is potentially deadly.

Do we really want to take away a woman’s right to self-determination?

Women’s right to control what happens to their bodies during pregnancy and birth may be enshrined in law but this right is frequently violated in practice. I find it ironic that the same professionals who fight for the right for a woman to terminate her pregnancy will fight against her right to give birth at home. The law in this country is on the side of women and self-determination.

To step into this and attempt to regulate a woman’s body has serious ramifications and undoes hard won battles our feminist forbears fought for with such vigor. The unintended consequences of regulating the ‘pregnant uterus’ should give us cause for sober reflection. Where do we stop once we start and who controls what is acceptable behavior and what is not?

I genuinely believe that most health professionals are united in the belief that a woman’s right to self-determination should be protected and is protective. There have been attempts of late to regulate midwives more closely to try and indirectly regulate women.

Midwives are being reported to their registering body AHPRA with increasing frequency and some of the reports are highly vexatious. This also is concerning because when midwives are forced to abandon women who step outside accepted guidelines, then freebirth (birth at home with no health professional in attendance) – which is rising in our country – becomes an even worse option with regards to safety.

The home birth is about more than safety

It is becoming increasingly apparent when midwives and obstetricians stop warring over the safety of home birth that the argument is far more complex.

The debate around home birth is about more than place of birth or associated perinatal mortality, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model and risk paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth and therefore should determine what is considered safe, the culture of childbirth in a country and the position and status of women within a society.

Home birth also represents starkly the different philosophical frameworks held by midwifery and medicine, and hence the debate over this issue is ideological, contested, longstanding and circumscribed by relationships of power.

Sadly it is rarely about women and women’s voices are often dismissed or denied in the debate.

It is time to stop talking about the statistics and start working together to make home birth and hospital birth as safe (physical, cultural, emotional, social, psychological and spiritual) as it can be.

Perhaps then the right women will give birth in the right place at the right time and with the right health care provider and have outcomes that are both safe and satisfying.

This endpoint is something we all agree on, now let’s work together to get there.

28 Comments

oovergro

These arguments assume that obstetricians are male- the womans body etc.
Hence discussion with underlying assumption of sexism
A quick look would show that the medical workforce is not male dominated.
There are a lot of female obstetricians.
They are as reluctant as their male colleagues to be involved in a situation that might leave a dead or maimed baby

john2066

Lets face it, the AMA are Australia’s most powerful trade union, and they will do anything in their power to maintain their monopoly over medical services. If that means stopping home births, they will stop home births. Ironically of course, they make sure there aren’t enough doctors regardless by restricting drastically specialist numbers.

Kim Bulwinkel

john2066
I am saddened by your comment. It shows great lack of knowledge and gives insight ++ into your preconceived ideas that unfortunately seem to also come all-too-frequently from the mouths of our federal & state politicians.
1] The AMA is not a Trade Union and has never been able to be. It is expressly disallowed from any trade union type role because of its structure as a diverse professional representative organisation.
2] The AMA has no control or even influence, unfortunately, over doctor numbers trained or registered in this country. Our calls for government to increase doctor training numbers in an orderly and sustainable way back in the mid 1990s were scornfully rejected with much personally directed invective [ I was on the receiving end ].
3] Specialist training requires practical training environments & posts, trainers, time to train, a realistic monetary value to be assigned to training and certain standards to be maintained. All of these issues are, again unfortunately, beyond any sort of control of the AMA. The facts are that most training of specialists is done on an honorary basis by College members/trainers [not AMA], training posts are linked to public hospital beds – all under great pressure of numbers, resources etc. [not under any control of the AMA]. Training of specialists takes TIME to do and time is under impossible efficiency pressures in public & private health delivery environments [ the AMA has no influence over the length of a minute, an hour or the number of hours in a day! ].
More modern generations of health care providers and students want a better work-life balance – much of the best training happens outside of those parameters [ again not controllable by the AMA ]. No one, including the AMA, has yet figured how to assign & allocate a financially viable value to the training process – everyone wants the outcome but no-one wants to pay!!
john2066, please think and learn before emotionally ‘lashing out’. You can ban the AMA if you like …. make them disappear and the only result will be that you will have no-one to blame. All else will remain the same.

liliwyt

Thanks Hannah. A thought-provoking piece. I agree that the definition of “safety” in regards to childbirth is limited, but understandable given the current business model of health care. Obstetricians are only interested in the successful delivery of a viable infant – that is what they are trained to do and the professional consequences for them are dire if the worst happens and the child or the mother dies as a result of the childbirth process. With the pressure of several mothers in labour and having to attend each one in a birthing unit, the obstetrician has at his/her disposal the tools to bring forward or delay a birth so that each mother receives “timely” care. All very ethical and above-board. That is not to say, however, that the definition can not be changed – a wider lens of maternal and infant health and wellbeing should be considered and this, I feel, is where the midwife model is applicable and is not inimical to the medical model.

In an ideal world midwives and obstetricians should be working together. This continuous sniping only does harm to all concerned.

Jenny Advocat

liliwyt, I agree with you except for the bit about “all very ethical and above board”. It depends from whose perspective you are look. It is certainly not ethical to induce my labor (or delay it!) or inject me with hormones to hasten delivery of the placenta (or any other of the tools at the disposal of the obstetrician) because of the pressure the obstetrician is under! Ethical childbirth can only be achieved when intervention is undertaken soley for the health of the mother and baby–not to conform to the time constraints of the system. If we broaden the definition, we will have to confront some of these practices which are about the system, not the individuals who enter it. I agree, working together is always preferrable, regardless of how realistic that is, the sniping won’t solve anything.

midwife

Everything old is new again. There is nothing new in this article. For 38 years practising responsible midwifery has always been about the woman and what she needs, never any argument about this. Midwives have and still work in mutually respectful relationships with general practitioners and obstetricians. Nothing has changed, and nothing is new in these recommendations, except for the interference of politicians who rub shoulders with the likes of Dr Pesce for their own political and financial gain. The new breed of AMA and Politics has some belief that they can control every other profession and women too. Not so, midwives will continue to fight for their professional rights, and women will fight for their bodily and womanly rights. Midwifery is a respected profession in it’s own right, mutual recognition of the very different skills does not mean control of one profession over another.
Midwives provide midwifery services not obstetrics, and vice versa. Midwives provide their services for women, in keeping with the International Confederation of Midwives and statuatory regulations. Midwives who are self-employed are not beholden to doctors or institutions, they are employed by, and contracted to the women and are accountable for their actions.
Most importantly midwives are not ‘support persons’ when they enter the institutuion with a woman they responsibly transfer for the opinion of another professional. Midwives, when they cross the threshold of the hospital entrance will not accept this insult of pseudo deregistration, change of status, or change of title just because they consult with a team of institutionally employed professionals. When midwives who work ‘with women’ in any setting consult and/or refer they do not change the status of MIDWIFE to ‘support person’, they do not relinquish their registration, qualification or experience. There is no ownership of the woman or the midwife. Harmony within the team depends on the respect individuals have for the woman, and they together are the link in consultation with her for the best possible outcome, each respected for their level of knowledge, their experience, and most importantly for their ability to sit and communicate with, and talk eye to eye, face to face, with the woman at her level, not over her in a stance of dominance.
There are many responsible doctors in the Australian community who happily respectfully work with women and midwives. So the debate that continues is more about removing the politicians, the modern poorly informed restrictions, and multitude of position statements and guidelines that attempt to impede the practice of the qualified midwife, and let the professionals who are skilled and mutually respect the woman and her rights get on with what they are educated and qualified to do. Hospitals are for the sick and injured, not for the healthy. Keeping women out of hospitals for the sick and injured, returning to Community Birthing Homes and facilitating homebirth for the majority of women is the safest, and most responsible way for pregnancy, labour, birth and postnatal 6 weeks in this country. Mature Midwife.

liliwyt

Hi Jenny – I agree, the “ethics” are questionable and perhaps I should have parenthesised that phrase as you did. My point was that, certainly from the obstetricians’ and hospital administrators’ pov, it is preferable to deliver a baby “safely” and in some respect to control the timing of that using the medical technology available to them. It is certainly not against the law to do so. And my understanding is that you would have a hard time finding an Ethics Committee that would disagree with that, although proving “informed consent” may be problematic.

Does that make it right? No. As a woman, I agree it is not ethical (using the purest definition of the term) to use those means as part of a system that is more interested in KPIs than my and my baby’s wellbeing.

Jenny Advocat

Hi liliwyt. Yes, when looked at from the pov of hospital docs and admins, true, that would look “safer” to them. But, (and I sense we are agreeing), if a broader view is taken, it would include better attention to the more subtle ways in which otherwise unnecessary (to health) interventions in a low risk, healthy pregnancy and birth, can impact upon the overall health and well being of both mothers. No one would argue against safety. However, our very understanding of the term “safe” requires some unpacking. I believe we haven’t even begun to understand (scientifically) the impact this kind of institutional treatment can have on mothers and babies.

Like the midwife above states, hospitals are for sick people (and I’m glad they are there when we need them, I take access to them as a right, an entity to be questioned and improved in an ongonig basis and called upon when necessary) but pregnant and laboring women should generally not be included in that category. To do so can only be politically driven and fear based.

BeverleyW

When I ask women why they choose home birth their reply is “I want to feel safe”. Home is where they feel safest. For some women this is their first birth – most are well read, but there are those that are not. For a few the choice is a “can do” idea. If there are problems of access to a midwife some search far and wide. The commitment to have a home birth is matched by the statements about giving birth as one of pure joy compared with previous experience/s in various hospital settings. Statements such as “why did I ever go to hospital?” I wish I had known that this is what it is like. Most women I speak with about choice of home birth, have experienced a traumatic time in hospital. They speak of feeling out of control, noisy place, the staff are rushed and if they had a surgical birth their baby was taken away to a special care nursery and they found this alarming. They felt that if they had agreed to have to have an induction and if it led to a Caesarian Birth they felt cheated especially when they found the reasons were specious if not wrong. Many had heard of home birth choice and that is what they want the right to do. There are those I also hear from who want a hospital birth because they need a break for a stressful situation at home and those reasons are sometimes because of abuse at home (usually alcohol related) and this is across the spectrum of poor or well off homes. Work related fatigue and large families is another reason for choosing hospital given by some women. Respite these days is really only for those that can afford private care – otherwise early discharge is the custom in public hospitals. I am interested that Dr. Pesce is still talking up mortality and not acknowledging morbidity – Post Natal Depression and post surgical fatigue and poor breastfeeding statistics due to lack of support and access to the baby as a result of major abdominal surgery and chemical inductions, haemorrhage, infection, episiotomy and sometimes even hysterectomy.

I am supportive of a better dialogue between professionals to achieve safe hospital birth and safe home birth. From my times when hospital birth prior to chemical and surgical terminations of pregnancy (inductions) was rare and when doctors were real and men were men and women had been running their own hospital in Melbourne (Queen Victoria). while the playing field was not fair or equal then there was respect for each other in that field – dialogue worked. For me dollar driven obstetrics means that dialogue is impossible when midwives are not acknowledged with remuneration nor are their private practices are not equally supported by government funds through Medicare. That “dog don’t hunt”.

I wonder whether those above are aware of threats to the current government about millions of AMA dollars would be spent to prevent midwives accessing Medicare. Doctor owned and subsidised Insurance is not an even playing field. When mortality rates in hospital are still around 9.00 per thousand with limited transparency of the why and Caesarian Rates are way above WHO recommended rates in private hospitals something in the state of this Nation is on the nose.

Yes there are female obstetricians but unfortunately their mentorship is not focused on care of the woman in labour of afterwards with breastfeeding it is focused on how fast can we get this woman in and out of hospital. One private obstetrician in a major teaching hospital refuses to come to births after 5.00 pm and encourages 38 week inductions on weekdays. When pushed by a woman who was able to disprove the supposed reason for the induction in her haste to expedite the normal vaginal delivery pulled on the cord and broke it. Leading to a great deal of distress for the grandmother the mother and the husband. The is woman was not allowed to move around in labour. Enuf said –

Kim Bulwinkel

Great debate! So much would be made much easier if the medico-legal implications, risks & costs of the types of decisions being discussed here were removed from the field of play in obstetrics & paediatrics completely.

Lets be novel and enshrine in water-tight legislation that women take full personal responsibility for their birthing choices and decisions. They can seek the education and opinion that they wish or are able to access. They make their decisions and then wear the full consequences of their decisions. Society doesn’t wear the cost consequences. Insurers don’t have to factor in the payout and legal process costs. Midwives and obstetricians are freed up from onerous protocols, legal standards and crippling costs. Decisions have consequences!

For the record, I am not an obstetrician or a medical practitioner that has ever had responsibility for a delivery in 34 years of practice.

Jenny Advocat

Kim, I’m all for personal responsibility, and certainly that plays a role. But let’s not pretend that anyone’s decisions are made in a vacuum. What information will be made available to women prior to making that decision? Which women will be empowered and which will be disadvantaged by such legistlation? There are a lot of things to consider before wiping our hands of social responsibility. As a society we are not very good at encouraging people or helping them to understand their bodies, I think a lot needs to change before personal responsibility can be at the centre of this debate.

Sue Ieraci

This essay presents an unusual view of the safety of birth – one which, I suspect, would not be supported by the majority of our community. Dahlen acknowledges that there are several well-defined risk-factors that threaten the lives of newborns in the homebirth situation. These include the readily-identifiable conditions of breech presentation and twins. If any other health care profession identified these causes of neonatal mortality and injury, but failed to adapt their guidelines to minimise the risk, there would be public outrage. How many parents truly value the home environment over the safety of their baby?

Dahlen presents the argument that perinatal mortality isn;t everything in birth safety – that maternal pshchological morbidity is important too. Of course it is. However, this essay reflects the other side of the argument – the severe and long-lasting psychological effects on BOTH parents of losing a child in childbirth. Is Dahlen really asserting that the psychological morbidity to a mother from having an unexpected cesarean delivery is greater than the extreme and ever-lasting grief for both parents of losing a newborn?

Finally, if it is true that the greatest cause of maternal death in the child-bearing years is psychological distress, we must remember that, in the past, it was childbirth. It’s important not to forget that the advances in clinical care for both pregnancy and delivery are the reason that maternal mortality within labour and delivery are so low in our societies. In the developing nations, where women cry out for access to the clinical care that we can be so critical of, the balance of safety is very stark.

liliwyt

Kim, I agree that the current medico-legal climate is not conducive to the kind of reforms we are discussing here. It could be argued that situation has come about because of specious compensation claims being made against doctors in general. It certainly has prevented many GPs from practicing obstetrics, which was much more commonplace 30 years ago.

Your point also seems to come from the perspective of the woman taking “full responsibility” for any harm that comes to her during childbirth. What about the consequences of poor decisions made by the medical staff attending her?

Yes, making women aware of their own personal responsibility is important – any patient, for that matter, should be playing a much more active role in the decision-making process around their health care. But it needs to be done by providing informed consent. That can’t be done until all the implications are discussed and it certainly can’t be done (as Jenny pointed out) when the patient has limited health literacy. When you consider that around 40% of all Australians have low levels of health literacy, taking such action as legislating for personal responsibility in childbirth becomes problematic.

Jenny @9 – yes, I agree the definition of “safety” needs to be looked at more broadly.

Kim Bulwinkel

I think that you miss my point. Specialist medical practitioners are energetically & aggressively pursued to be made responsible for outcomes that they often have not been able to influence despite their best of intentions and the best possible applications of their knowledge, time, experience and skills. This comes at great personal, emotional & financial cost. The AMA tries hard to find the right solutions from a professional point of view but always seems to attract the invective of the type that is being used in the above commentary – very unfair & ill-informed.

Midwives and their clientele have to realise that if they want the inevitable problems with a percentage of deliveries to be miraculously and effectively dealt with, they will need the input of skilled obstetricians and paediatricians. There will be a significant percentage of significant problems. The specialists will then be aggressively and energetically made responsible as soon as they answer the telephone, receive a fax to their rooms or even walk past the end of room or corridor.

Surely everyone involved in this debate must understand that this paradigm is not sustainable or even tolerable. Don’t take the wheels off the car before it has stopped travelling at 100 kph!!

liliwyt

Kim – I take your points, coming from the current paradigm, and I agree that what is being argued here may not fit easily into that paradigm.

For myself, I don’t think that childbirth should be the sole domain of the midwives OR the medical specialists, but that their roles are complementary.

Let’s take a hypothetical for a walk …

A woman discusses her birthing plan with a midwife early in the pregnancy. That plan includes all possible scenarios. The woman is screened for potential complications at specific points during the pregnancy. If there is a possibility that a complication could arise, the woman meets with an obstetrician (not necessarily the one that is on duty when she is in childbirth – given the variability in delivery dates & times and rosters, etc) to discuss possible medical interventions. Counselling on what the woman could expect in childbirth continues throughout the pregnancy, led by the midwife, supplemented by information from the obstetrician. At some point, well before she goes into labour, the woman signs a written agreement which outlines the birthing plan, all things considered.

Jenny Advocat

Kim, yes, I may be missing your points. I am interested in the majority of ‘normal’ births, low risk, without problems, and you seem to be talking about some (“significant”?) percentage requiring necessary emergency intervention. I question the need for calling for so much intervention and suspect the true emergencies would be fewer and farther between if we had a health system that worked better with women and educated practitioners to respect and cultivate knowledge about the body which is being lost. You seem to be coming from a position of defending medical practitioners (which is fine) but, as neither a medical practitioner nor someone working for them, I am more interested in mothers and babies. I take your point that there is a lot of pressure on practitioners to get it right, but I wonder, why don’t midwives working outside the hospital system have such a big problem with medico-legal issues?

Sue Ieraci

Jenny – you ask “why don’t midwives working outside the hospital system have such a big problem with medico-legal issues?”

Firstly, in Australia, there are very few of these. Secondly, if they work within the guidelines, they have to follow risk-out guidlines and having a workign relationship with an obstetrician (to get indemnity cover). If they are registered midwives, working under these circumstances, then they are accountable for their decisions. The number of independent midwives working under these conditions, with indemnity cover, is very small. The number of high-risk homoe births they manage must therefore be close to zero.
On the other hand, the home birth deaths that are currently being investigated by the SA coroner have occurred in the hands of some pracititoners who have stepped outside the regulatory framework by rejecting registration – and therefore accountability. They cannot (in practical terms) be sued if they don’t carry insurance. And lastly, the women who want to birth with them believe in them so strongly that they are highly unlikely to hold them accountable.

Kim Bulwinkel

The doctors are the easy target who have the insurance & therefore the source of financing to feed the needs, real perceived or otherwise. This is the biggest issue, not the righteous reasons usually put up by the idealists. Maybe the answer is to encourage that the obstetrician should go the way of the procedural GP. I believe that this scenario actually played out in Nevada USA not so long ago & continues to be a major issue. …. http://www.soroptimist.org/articles/article_obstetricians.html.

Watch what happens to the medicolegal issues that midwives will face when the source of sueable funding disappears.

It is sad but true that this debate probably doesn’t have a satisfactory outcome without the removal of the medicolegal, training and acceptable standards issues.

midwife

It’s obvious this debate is not changing anything, medical practice is fear based, fear of he medico-legal implications, fear of midwives making midwifery decisions with women, fear of midwifery being a rightful profession. Pegnancies continue, modern medicine is never in a position to make the right decisions all the time, neither is any other profession. However, most of the time they do make the right decisions. The fear of midwives is about control of the profession. So doing what has been done for centuries and is still alive amongst sensible professionals. Consult and refer both ways, talk to each other on equal terms and leave the politicians out of professional decision making.

liliwyt

Kim – I for one don’t believe that obstetrics will become obsolete because midwifery is asking for equal recognition and I don’t think that is what the midwives are advocating for. From my own experience, if it wasn’t for my obstetrician, I wouldn’t be alive and, probably, neither would my son. And I’m sure there are many women who would tell similar stories. Of course obstetricians have a role to play. As midwife @20 says “consult and refer both ways (between midwives and obstetricians), talk to each other on equal terms”. How is that threatening to obstetricians?

Are you saying that medical doctors are continually living under fear of being sued by their patients? Is this perception based in reality?

Kim Bulwinkel

Liliwyt – The short answer is yes. Any co-operative model between nurse practitioners, midwives, physician assistants will expose the medical practitioner / specialist to the not insignificant risk of being held responsible for the outcome of any management event. The insurers factor in that risk then charge an appropriate premium.
Even answering the telephone or having a “corridor hypothetical” can be now used to pull in the medical practitioner into the legal mire. There is currently no such thing as “equal terms”. I hope you read my link posted above.

The only way out of this difficult situation if you want to advance your ideals without changing the current rules at present is for the medical practitioners / specialists to bow out and leave it to “other health professionals”. The maternal and perinatal morbidity and mortality statistics of 100+ years ago make interesting reading. I am personally glad that I am very close to quitting in my own field.

liliwyt

Hi Kim – I’ve read that piece and I agree that the soaring costs of medicolegal insurance are pricing a lot of Australian doctors out of some types of medical practice, including obstetrics. This has been an issue since the 1980’s and, for me, is more a whole-of-system problem than due to a tension between medical practitioners and allied health practitioners. In some cases, it could be argued that allied health practitioners (like midwives) have been given more access to patients to cover the gaps left by doctors who have left the field. But is that the fault of the allied health practitioners?

Personally, yes, I think if midwives (and other AHPs) want equal professional recognition then they should also be held equally liable if something does go wrong. Again, I don’t think anyone in this debate is suggesting that obstetricians should be left to carry the can legally, but I do see that putting obstetricians in the position of only dealing with childbirth in an emergency situation where there is a higher risk of complication, leading to a potential litigation, is not ideal.

Again, it comes down to the current system. It’s clearly not working for many doctors, not just obstetricians. But attacking midwives for wanting collaboration is not a very effective way of dealing with the issue. All health workers should be working together to deal with the medicolegal monster.

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It is polite and political, informative and inspiring. Active engagement is what Croakey does – and I like it!

Professor Kerry ArabenaChair of Indigenous Health, The University of Melbourne

If news doesn’t make you squirm it’s simply propaganda. Croakey’s unique blend of activism, humour and plain good reporting makes it an essential - if not always comfortable - read!

Professor Virginia BarbourExecutive Officer, Australian Open Access Support Group, Chair, COPE, Professor, School of Medicine, Griffith University

Croakey is an important part of the health landscape providing progressive, current and incisive commentary.

Professor Fran BaumProfessor of Public Health, Flinders University

Croakey is terrific. Thought provoking, well researched information….and easy to read. A great combination.

Professor Kate ConigraveProfessor Addiction Medicine, The University of Sydney

Croakey has been a platform which has encouraged Aboriginal voice and actively sought it out. I started out as a reader, then followed on Twitter, was a guest tweeter on @WePublic health, and have become a contributor.

Croakey is now well established as compulsory reading for influencers and observers in health and medicine in Australia and internationally – and rightly so.

John FlanneryPublic Affairs Director, Australian Medical Association

Croakey provides an informed voice to the health, equity and environmental debates, and is helping mobilise the necessary political and popular support for a radical break from the complacent and compartmentalized attitude that still dominates much of the political agenda.

Professor Sharon FrielDirector and Professor of Health Equity Regulatory Institutions Network (RegNet), Director, Menzies Centre for Health Policy, The Australian National University

From a crowded inbox, Croakey always leaps to my attention. It delivers views and information on a wide range of issues of relevance to rural and remote health and wellbeing.

Gordon GregoryNational Rural Health Alliance

Croakey is health media rather than medical media. You should be reading it every day if you're interested in health services or population health.

Ben Harris-RoxasZEST Health Strategies

Croakey provides snappy, expert views on the whole spectrum of public health issues, from equity to efficiency, from determinants to prevention to management.

Professor Jon KarnonSchool of Population Health, University of Adelaide; President of the Health Services Research Association of Australia and New Zealand

Croakey has served splendidly as an independent voice in the health policy arena.

Emeritus Professor Stephen LeederThe University of Sydney

Time and again I go to Croakey to understand the politics behind public health because Croakey sorts the wheat from the chaff.

Dr Mark LockResearch Fellow, The University of Newcastle

I love the context and clarity that Croakey's contributors bring to very complex issues. And the merch.

Marie McInerneyjournalist, editor, Croakey moderator

Croakey has pioneered an unprecedented role in providing an open forum for the revelation and exchange of thinking on health in Australia.

Mark Metherellhealth journalist, CHF

Croakey - like a sore throat spreading amongst friends - helps to spread healthy ideas rapidly through the blog and the Twittersphere. Thank you Croakey.

Michael MoorePublic Health Association of Australia

Croakey - Australia's healthiest news-site!

Former MP, Rob Oakeshott

If you work in the health area – and especially if you are a policy wonk, a political nerd, or a news fiend – then Croakey Blog is an essential component of your life.

Lesley RussellAdj Assoc Professor at Menzies Centre for Health Policy, University of Sydney, Visiting Fellow, Australian Primary Health Care Research Institute, Australian National University

The diversity of authors and timeliness of posts are very much appreciated. Bring me more of this!

One of my favourite things about Croakey is the active engagement of so many people with a passion for equity and public health.

Melissa Sweetpublic health journalist, Croakey founder, PhD candidate

Croakey cuts through health care professional and organisational interests with edgy critiques about the diverse communities they are there for. In other words, you call BS on those with self interest.

Jason TrethowanCEO PHN Western Victoria

Croakey is a must for anybody looking to stay on the cutting edge of health news.

Alison VerhoevenAustralian Healthcare and Hospitals Association

So happy to be creating and coding for such a dedicated, professional and good-humored team.

Mitchell WardArtistic Director of Rock Lily Design and Croakey

If you care about a public health issue, or want others to care, get it online and get it on Croakey.

Croakey is a space that invites us to to challenge and interrogate our practice and our policy.

Mary FreerChange Day Australia

Croakey is a valuable voice in the health space

Catherine KingShadow Minister for Health

Croakey is a must read for anyone who craves the public health stories that no one else reports.

Dr Becky FreemanSydney School of Public Health, University of Sydney

We love the difference Croakey makes to the health conversation in Australia.

Professors Marc Tennant, Estie Kruger and Kate Dyson International Research Collaborative, Oral Health and Equity, The University of Western Australia.

The broad mix of contributors, topics and prolific tweets combine to make it a valuable and lively source of news and food for thought for all Australians.

Shauna Hurley Communications Manager, Cochrane Australia School of Public Health and Preventive Medicine, Monash University

Croakey is the platform where health issues are dissected from every angle – from the complex impact on health arising from social, economic and environmental policies, to the influence of vested interests on public health, and insightful analysis of health care policies.

Marita Hefler Researcher, News Editor, BMJ Tobacco Control

Croakey gives me the best independent and most relevant public health news and views.

Croakey has, over some years, provided a platform for debate about health policy, planning, funding and services. There aren’t enough places for these debates, and important issues affecting the health of our community risk going unexplored. Croakey helps to fill this hole.

Croakey is one of the few places where public health "activists" can vent their spleen...It's also a useful place for journalists/media to find contacts who can speak intelligently on public health issues.

Dr Rosemary Stanton OAM Public health nutrition "activist"

Intelligence and thoughtfulness are pre-requisite foundations for a civilised society’s media, and Croakey rises above the mundanity of most Australian efforts to remind us that smart, switched-on writers and thinkers are still out there

As CEO of the Victorian Mental Illness Awareness Council (VMIAC), it is my pleasure to write a testimonial for Croakey. In the past three years, VMIAC have happily engaged the services of Marie McInerney and her team at Croakey to cover major events in the life of VMIAC. We have been fortunate to have Croakey

Maggie TokoCEO of the Victorian Mental Illness Awareness Council (VMIAC)